Anterior and Medial Thigh (Cadaver Supine) Unit 10 Anterior and Medial Thigh (Cadaver Supine)

Learn the Three Compartments in the Thigh, Actions and Nerve Supply Thigh: Cross Section Preview Plate 505 Anterior Compartment Femoral Nerve Extension of Knee Learn the Three Compartments in the Thigh, Actions and Nerve Supply Medial Intermuscular Septum A M Medial Compartment Obturator Nerve Adduction of Thigh F Fascia Lata and Iliotibial Tract Lateral Intermuscular Septum P Posterior Intermuscular Septum Posterior Compartment Sciatic Nerve Extension of Thigh and Flexion of Knee Right thigh from feet looking up

This is the Lumbar Plexus formed by ventral rami of L1 - 1/2 of L4 Preview Plate 498A T12 This is the Lumbar Plexus formed by ventral rami of L1 - 1/2 of L4 L1 L2 L3 Femoral Nerve L2-4 L4 Medial compartment: Obturator nerve L2-4 anterior divisions Anterior compartment: Femoral Nerve L2-4 posterior divisions L5 Obturator Nerve L2-4 Anterior Division Posterior Division

These are SOMATIC NERVES! Lumbosacral trunks (1/2 L4-L5) Plate 498B These are SOMATIC NERVES! Subcostal T12 L1 Iliohypogastric & Ilioinguinal L1 L2 L3 L4 Genitofemoral L1,2 Lat. Femoral Cutaneous L2,3 L5 Lumbosacral trunks (1/2 L4-L5) Femoral L2-4 Obturator L2-4

Bony Framework Plate 248 Palpate or Locate Anterior Superior Iliac Spine Pubic Tubercle Inguinal Ligament Obturator Foramen Anterior Superior Iliac Spine Inguinal Ligament Anterior Inferior Iliac Spine Aponeurosis of External Oblique Muscle Obturator Foramen Pubic tubercle

External Oblique Muscle Inguinal Ligament Plate 249 External Oblique Muscle Aponeurosis ASIS Inguinal Ligament The inguinal ligament is the lower edge of the aponeurosis of the external oblique. It is rolled over on itself and attaches to the ASIS and the pubic tubercle. Pubic Tubercle

Palpate/Locate Patella Tibial Tuberosity Bones Plate 513A Palpate/Locate Patella Tibial Tuberosity Quads Tibial Tuberosity P Feel the Patella, a sesamoid bone in the tendon of the Quadriceps Muscle Medial

Preserve the Great Saphenous Vein Superficial Veins Plate 544 Preserve the Great Saphenous Vein Great Saphenous Vein Used in coronary by-pass surgery Originates on the dorsum of the foot from the dorsal venous arch and ascends anterior to the medial malleolus, up the medial side of the leg and thigh to empty into the femoral vein after piercing the fascia lata at the saphenous opening. Great Saphenous Vein Dorsal Venous Arch

Superficial Veins “Saphenous Cut-down” for emergency transfusions; GS Vein is ALWAYS present in front of medial malleolus In infants, obese people and patients in shock (vein is collapsed in the latter), you may not be able to find the greater saphenous vein. It can be always be found anterior to the medial malleolus! Medial Malleolus Page 584 Moore

These veins can become “varicose” Superficial Veins Page 583, Moore These veins can become “varicose” Direction of blood flow normally Due to incompetent valves of perforating veins that connect deep veins with superficial veins Calf Muscular Pump: return of blood to heart against gravity Blood flow changes direction: from deep to superficial Can be due to a tumor in abdominal cavity, obesity, genetics (weak valves).

(Extensor Compartment) Anterior Compartment Femoral Nerve (Extensor Compartment)

Clean and Identify Fascia Lata Saphenous Opening Plate 544 Clean and Identify Fascia Lata Saphenous Opening Saphenous Opening in Fascia Lata Greater Saphenous Vein The Greater Saphenous Vein terminates in the Femoral Vein here

Locate Iliotibial Tract Tensor Fasciae Latae Anterior Thigh Plate 494 Locate Iliotibial Tract Tensor Fasciae Latae What is the TFL’s innervation?

Muscles in the Anterior Compartment

Identify, transect, and reflect Sartorius Anterior Thigh Plate 492A ASIS Identify, transect, and reflect Sartorius The Sartorius is the “tailor’s” muscle – flexes, abducts, laterally rotates thigh and flexes leg Sartorius Using both muscles brings you into a cross-legged sitting position Sartorius can be pulled off of the ASIS with some bone pulling off as well – avulsion. Medial

AP radiograph of pelvis: prior healed avulsion fraction of ASIS

Transect the Rectus Femoris Anterior Thigh Plate 492A Identify the “Quads” or Quadriceps Femoris 4 Heads: Vastus Lateralis Vastus Medialis Rectus Femoris Vastus Intermedius Rectus Femoris Vastus Lateralis Transect the Rectus Femoris Vastus Medialis Medial

After transecting Rectus Femoris - identify the Vastus Intermedius Anterior Thigh Plate 492B After transecting Rectus Femoris - identify the Vastus Intermedius Origin of Rectus Femoris can be avulsed during forceful kicking AIIS Vastus Intermedius Note: the origin of the Vasti muscles is from the shaft of the femur but the Rectus Femoris originates from the AIIS The rectus femoris is the kicking muscle and can be avulsed from the AIIS during kicking. Medial

Action: Extension of leg at knee joint All 4 heads of the quads insert into the tibial tuberosity via the Patellar Ligament Anterior Thigh Plate 507A Quadriceps Tendon Action: Extension of leg at knee joint P Who is most likely to be a victim of Osgood-Schlatter Disease? Disruption of the epiphysial plate at the tibial tuberosity may inflammation of the tuberosity and chronic recurrent pain during adolescence. Osgood-Schlatter disease is probably the most frequent cause of knee pain in children. The condition occurs most commonly in children between the ages of 10 and 15 years but it can occur in younger children. Both boys and girls are equally vulnerable to its debilitating effects. Osgood-Schlatter disease is always characterized by activity-related pain that occurs a few inches below patella on the front of the knee. The child will have swelling in the area, and tenderness to touch. Sports requiring lots of running, jumping, kneeling, and squatting are particularly associated. Many children first signal the start of the problem by rubbing the top of their "shinbones" with their hands, or even ice cubes, at practice sessions. The three main factors that contribute to Osgood-Schlatter are: 1. Between 10 and 15 years old. 2. Involved in youth sports. 3. In a "growth spurt". Patellar Ligament Read about Osgood-Schlatter disease, Moore, page 568 inflammation of tibial tuberosity with chronic pain Tibial Tuberosity Medial

Anterior Thigh Plate 543B Reflex Hammer Patellar Tendon Reflex or knee jerk – tests L2-4 spinal cord segments and the femoral nerve; page 597 Moore

Femoral Triangle and Contents

Identify boundaries of the Femoral Triangle Anterior Thigh Identify boundaries of the Femoral Triangle

Identify Femoral Nerve Emerges below Inguinal Ligament Anterior Thigh Plate 538A Lumbar Plexus Femoral Nerve L2-4 Identify Femoral Nerve Emerges below Inguinal Ligament Obturator Nerve Femoral nerve innervates the muscles in the anterior compartment.

Identify Femoral Artery Femoral Vein The nerve is not! Anterior Thigh Plate 546C External Iliac Vessels Identify Femoral Artery Femoral Vein The nerve is not! ASIS Femoral sheath N Inguinal Ligament Pubic Tubercle Note the vessels are encased in the Femoral Sheath A V

There are 3 compartments formed by the Femoral Sheath Anterior Thigh There are 3 compartments formed by the Femoral Sheath Note Femoral Canal Lateral 1 N Intermediate 1 Medial A 2 V 3 L E Moore page 601 Spell NAVEL

Lateral to pubic tubercle Anterior Thigh Note Femoral Hernia in Femoral Canal Moore page 606 More common in females Lateral to pubic tubercle

Note the Saphenous Nerve Plate 500B Anterior Thigh Femoral Nerve, Artery and Vein Saphenous Nerve Adductor Canal Remove the Femoral Sheath and follow the Femoral Vessels into the Adductor Canal and through the Adductor Hiatus The adductor canal is an intermuscular passageway by which the neurovascular bundle of the thigh traverses the middle third of the thigh. Sartorius forms the roof of the canal and adductor longus the floor. Adductor Hiatus Note the Saphenous Nerve

There are two muscles that form the floor of the Femoral Triangle Plate 492A Anterior Thigh Pectineus One is the Pectineus muscle which is variably supplied by the Femoral Nerve and the Obturator Nerve There are two muscles that form the floor of the Femoral Triangle A flexor and adductor of thigh Medial

The other is the Iliopsoas Plate 496 Anterior Thigh The other is the Iliopsoas Iliopsoas Psoas Iliacus Inserts on lesser trochanter The iliacus and the psoas muscle come together to form the iliopsoas – inserts on the lesser trochanter. The strongest flexor of hip joint

Identify branches of Femoral Artery Deep Femoral Perforating Branches Plate 512 Anterior Thigh Femoral Artery Identify branches of Femoral Artery Deep Femoral Perforating Branches Deep Femoral Perforating branches Medial

Plate 512 Anterior Thigh The deep femoral artery has two other significant branches Lateral Circumflex Femoral Medial Circumflex Femoral Lateral Circumflex Femoral Medial Circumflex Femoral Deep Femoral Artery These are critical for blood supply to head of femur especially medial circumflex femoral artery

Retinacular branches are most important Moore, page 680 Deep Retinacular branches are most important

Summary Anterior Compartment Nerve Supply: Femoral Nerve Blood Supply: Branches of Femoral Artery Action of Muscles: Extension of Leg at Knee and Flexion of Thigh at the Hip

Obturator Nerve (Adductor Compartment) Medial Thigh Obturator Nerve (Adductor Compartment)

Divide and reflect Adductor Longus Plate 492B Medial Thigh Expose and Identify muscles of the adductor/medial compartment Gracilis Adductor Longus Adductor Brevis Adductor Magnus Adductor Longus P Gracilis Gracilis adducts the thigh and flexes the leg – crosses two joints. Divide and reflect Adductor Longus

Identify Adductor Brevis Plate 500 Medial Thigh Divided Adductor Longus Identify Adductor Brevis P Sartorius AL Adductor Brevis Gracilis Medial

Identify Anterior and Posterior branches of the Obturator Nerve Plate 500 Medial Thigh Obturator Nerve Identify Anterior and Posterior branches of the Obturator Nerve Adductor Brevis Medial

Identify Adductor Magnus Plate 493 Medial Thigh Identify Adductor Magnus This muscle receives branches from two nerves: Tibial and Obturator Adductor Magnus Foramina for Perforating branches The “hamstring” part of the Adductor Magnus originates from the ischial tuberosity and inserts on the adductor tubercle of the femur - innervated by the tibial nerve. Adductor Hiatus “groin pulls” = strain “Hamstring part”

The adductor muscles adduct the thigh at the hip joint Attachments Plate 491 Pectineus Adductor Longus Note origins of the adductor muscles; they mostly insert on the back of the femur Gracilis Adductor Brevis Adductor Magnus The adductor muscles adduct the thigh at the hip joint Linea Aspera Posterior

Greater Saphenous Vein Plate 485 Surface Anatomy Inguinal Ligament Sartorius Rectus Femoris Vastus Lateralis Vastus Medialis Gastrocnemius Greater Saphenous Vein Patella Ligament

Summary of Medial Compartment Nerve Supply: Obturator Nerve Blood Supply: Obturator Artery Action of Muscles: Adduction of thigh at hip joint

Hip Joint

Stable articulation between the head of the femur and acetabulum Hip Joint Plate 488 Ilium X-Ray Hip Joint Left Side A Head Greater Trochanter Pubis Neck IC IT Lesser Trochanter Obturator Foramen Ischium Femur Stable articulation between the head of the femur and acetabulum

Iliofemoral (Y) ligament Plate 487A Hip Joint Hip Joint Ball and Socket Strong Capsule Reinforced by ligaments: Iliofemoral Pubofemoral Ischiofemoral Iliofemoral (Y) ligament Iliofemoral ligament attaches to AIIS and acetabular labrum superiorly and the intertrochanteric line distally. Prevents hyperextension of hip joint – strongest ligament in the body. Pubofemoral ligament prevents overabduction of the hip joint. Pubofemoral ligament

Posteriorly, note Ischiofemoral ligament Plate 487B Hip Joint Posteriorly, note Ischiofemoral ligament Sciatic nerve is in danger in a posterior dislocation Weakest of three ligaments.

Note head of femur and acetabulum Plate 487C Hip Joint Note head of femur and acetabulum Ligamentum of the Head: can be an important blood supply to head of femur- branch of Obturator artery Ligament of the Head A H Obturator Artery

Limb is laterally rotated and shorter Femoral Fracture: fractures of femoral neck in elderly people are problematic because of disruption of blood flow to the head of the femur (most important is medial circumflex femoral artery - often torn when neck is fractured). Avascular septic necrosis may occur. Intracapsular fractures are the most problematic. Elderly folks usually twist and fracture their femoral necks, then fall. Moore, page 682 Limb is laterally rotated and shorter

Retinacular arteries are in danger of disruption with a neck fracture Plate 512 Hip Joint Retinacular branches Lateral Circumflex Femoral Medial Circumflex Femoral Deep Femoral Artery Retinacular arteries are in danger of disruption with a neck fracture

Hip Joint Congenital dislocation of the hip occurs 1.5 per 1000 births, bilateral in half of the cases, girls 8x more than boys. Hip dislocation can be congenital or acquired (uncommon except in traumatic injuries). Posterior dislocations are most common. Moore, Page 683

Limb is medially rotated and shorter Hip Joint Limb is medially rotated and shorter

Laboratory/Quiz The dissectors for Unit 11 should remove the skin from the anterior leg and dorsum of foot before Wednesday’s dissection

Finish removing skin from anterior and lateral leg to dorsum of foot